• Commercial Allergy Testing and Treatment Policy (NEW)

    Payment policy #5006 is a new policy for the Commercial line of business.

  • Medicaid Allergy Testing and Treatment Policy

    Payment policy #4394 has been revised to include additional clarification.

  • Medicaid Pediatric and Neonatal Critical and Intensive Care

    Payment policy #3986 has been revised to include additional clarification.

  • Retirement of Select Medicare Payment Policies

    We are notifying providers that several Medicare payment policies are being formally retired. These policies are being retired to align with CMS standards and eliminate duplicative or potentially conflicting guidance. Providers should follow Centers for Medicare & Medicaid Services (CMS) guidance for appropriate billing and coding requirements for the Medicare line of business, including the Dual Special Needs Plan (also known as D-SNP). Providers are expected to follow current CMS rules when submitting Medicare/D-SNP claims, including but not limited to: Medicare Claims Processing Manual, Medicare Benefit Policy Manual, National Correct Coding Initiative (NCCI) edits, and CMS transmittals and Medicare Learning Network (MLN) publications.

  • Medicaid Drug Testing Payment Policy (Retired)

    Medicaid Payment Policy #4073 will retire on September 30, 2026. Providers should refer to the T2015 Prescription Medication and Illicit Drug Testing in the Outpatient Setting Medicaid Reimbursement Policy located on the Laboratory Benefit Management section of the provider website for additional information.

  • Retirement of Select Medicare Payment Policies

    We are notifying providers that several Medicare payment policies are being formally retired. These policies are being retired to align with CMS standards and eliminate duplicative or potentially conflicting guidance. Providers should follow Centers for Medicare & Medicaid Services (CMS) guidance for appropriate billing and coding requirements for the Medicare line of business, including the Dual Special Needs Plan (also known as D-SNP).

  • Laboratory Services Payment Policy

    Payment Policy #4390 and #4396 have been revised to include additional language regarding sexually transmitted infection testing billing and coding.

  • Medicare/D-SNP Billing and Coding (NEW)

    As we formerly retire existing Medicare payment policies to reduce duplicative guidance, we are introducing a new Payment Policy that will serve as the Medicare payment policy resource for billing and coding guidance for Medicare claims, including Dual Special Needs Plan (D-SNP) claims.

  • Retirement of Select Medicare Payment Policies

    We are notifying providers that several Medicare payment policies are being formally retired. These policies are being retired to align with CMS standards and eliminate duplicative or potentially conflicting guidance. Providers should follow Centers for Medicare & Medicaid Services (CMS) guidance for appropriate billing and coding requirements for the Medicare line of business, including the Dual Special Needs Plan (also known as D-SNP).

  • Sexually Transmitted Infection Testing (Retired)

    Payment Policy #4072 will retire for all lines of business. Providers should refer to the Laboratory Services payment policies for additional information.

  • Observation Payment Policy Update

    Medicaid & Commercial Plans Payment Policy #3836 has undergone annual review and update. Medicare Payment Policy #4546 will be retired.

  • CPT 88305

    Effective May 31, 2026 (Professional) / June 30, 2026 (Facility), CPT code 88305 will now be considered as a part of the Daily Maximum Frequency editing for Sentara Health Plans. Sentara Health Plans will limit reimbursement of CPT 88305 based on a maximum number of units per member, per provider, per date of service. Services billed in excess of the established daily maximum units will be denied as not medically necessary or not separately reimbursable.

  • Physical Status Modifier

    Effective June 15, 2026 (Professional) / July 15, 2026 (Facility), procedures billed with modifiers P3, P4 or P5 will be reimbursed based on the base units of the anesthesia procedure only; no additional reimbursement will be considered for these modifiers.

  • Robotic Assisted Surgery

    Effective August 28, 2026, Sentara Health Plans will no longer reimburse cpt codes 0054T-0055T, 20985, 61781-67183, and 69990, as they bundle into the primary surgical procedure.

  • Vitamin D Testing

    Effective July 14, 2026 (Professional) / August 14, 2026 (Facility), Vitamin D testing requirements will follow the LCD set forth by Palmetto GBA/CMS, which requires specific ICD-10 diagnosis codes when billing with Vitamin D CPT procedure codes 82306, 82652, and 0038U.

  • Operations Update - Revised Provider Reconsideration Form

    Effective October 23, 2025, Sentara Health Plans announced availability of the redesigned Provider Reconsideration Form to improve efficiency and ensure accurate routing of all requests.

  • Commercial Behavioral Health Authorization Fax Numbers and Forms

    Commercial Behavioral Health authorization fax numbers and forms for urgent and non-urgent requests.

  • Government Behavioral Health Authorization Fax Numbers and Forms

    Government Behavioral Health authorization fax numbers and forms for urgent and non-urgent requests.

  • Medicare Severity Diagnosis Related Groups (MS DRG) 870 Claims for Septicemia or Severe Sepsis

    MS DRG 870 reports claims for septicemia or severe sepsis with mechanical ventilation greater than ninety-six hours. The edit will deny claims for MS DRG claims when the discharge status is not equal to (02,05,30,82,85) and reports with inpatient procedure code 5A0955A and the length of stay less than 96 hours.

  • Sexually Transmitted Infections

    Sentara Health Plans will deny claim lines when two or more of the service codes listed below are billed by the same provider on the same date of service including when modifier 59 is applied.